Educational intervention to enhance the knowledge of Ghanaian health workers on Alzheimer’s disease and related dementias

Background Alzheimer’s disease and related dementias (ADRDs) pose a major public health challenge in older adults. In sub-Saharan Africa, the burden of ADRD is projected to escalate amidst ill-equipped healthcare workers (HCWs). Aim This study aimed to assess ADRD knowledge amongst Ghanaian HCWs and improve gaps identified through a workshop. Setting Study was conducted among HCWs attending a workshop in Kumasi, Ghana. Methods On 18 August 2021, a workshop on ADRD was organised in Kumasi, Ghana, which was attended by 49 HCWs comprising doctors, nurses, pharmacists, social workers and nutritionists. On arrival, they answered 30 pre-test questions using the Alzheimer’s Disease Knowledge Scale (ADKS). A post-test using the same questionnaire was conducted after participants had been exposed to a 4-h in-person educational content on ADRD delivered by facilitators from family medicine, neurology, geriatrics, psychiatry and public health. Results The mean age of participants was 34.6 (± 6.82), mean years of practice was 7.7 (± 5.6) and 38.8% (n = 19) were nurses. The mean score of participants’ overall knowledge was 19.8 (± 4.3) at pre-test and 23.2 (± 4.0) at post-test. Participants’ pre-test and post-test scores improved in all ADKS domains. Factors associated with participants’ knowledge at baseline were profession, professional rank and the highest level of education attained. After adjusting for age and sex, participant’s rank, being a specialist (adjusted β = 14.44; 95% confidence interval [CI] = 7.03, 21.85; p < 0.001) was an independent predictor of knowledge on Alzheimer’s disease. Conclusion Existing knowledge gaps in ADRD could be improved via continuous medical education interventions of HCWs to prepare healthcare systems in Africa for the predicted ADRD epidemic.

http://www.phcfm.org Open Access The regional differences in prevalence of ADRD may be due to different diagnostic criteria and screening tools, sociocultural dimensions such as stigma, which prevents early report of symptoms and various degrees of awareness or understanding about the disease. 8 Changes in anatomy of neurons, establishment of adult brain structure, early life exposures and genetic factors have been postulated to underlie an individual's risk of developing ADRD. 9 However, its exact aetiology remains elusive, there is currently no definitive cure and knowledge about the disease is limited.
Undoubtedly, healthcare workers' (HCWs') knowledge of ADRD makes a significant difference in early detection, effective intervention, support for carers and progression of the disease. At least 25% of cases of ADRD with mild manifestations are missed at the primary care level. 1 A study has predicted a 9.2 million decline in number of ADRD cases if an intervention is provided to achieve at least a one-year delay in disease onset and progression. 10 However, there are knowledge gaps and a lack of awareness amongst HCWs about the disease and this has been documented elsewhere. 11 The authors therefore sought to assess Ghanaian HCW's knowledge on ADRD before and after participating in a workshop on the subject. They also solicited their resolutions and recommendations on measures to enhance knowledge and minimise the impact of the disease.

Study design
This was a pre-and post-test cross-sectional study involving a sample of healthcare professionals working in both public and private facilities in Kumasi, Ghana. Participants included doctors, nurses, pharmacists, social workers, nutritionists and public health practitioners working in primary, secondary and tertiary institutions who were invited to attend a workshop on ADRD on 18 August 2021.

Workshop proceedings and data collection
As participants reported to the venue, they were welcomed and, after registration, a pre-test questionnaire using the Alzheimer's Disease Knowledge Scale (ADKS) was shared with them. The ADKS is a 30 true-false questions validated tool, which has previously been used in other studies. 12,13 Participants voluntarily provided answers to the questionnaire that were returned to workshop organisers before presentations by facilitators. The facilitators were a family physician, a neurologist, a geriatrician, a psychiatrist and a public health specialist. Topics treated ranged from epidemiology of the disease, clinical manifestations, diagnosis and treatment, providing support for families and carers and mental health issues associated with ADRD. After the presentations, a post-test using the same ADKS questionnaire was conducted to determine any change in participants' knowledge.
Participants were placed in five heterogeneous groups of maximum ten members who listed personal resolutions on how they would apply the knowledge acquired during the workshop in their daily work and also provided a list of recommendations to policymakers on how to better address ADRD in Ghana.

Statistical analysis
Demographic data were obtained from participants and the scores from the ADKS questionnaire. Data were entered into an excel spreadsheet for data quality management. Two independent data officers cleaned the data to ensure that there were no wrong and double entries. The data were merged and later checked for consistency.

Demographic characteristics of participants
The mean age of participants was 34.6 (± 6.8) years with a minimum age of 22 years and a maximum age of 50 years. More than half (51.0%, n = 25) of the participants were females. About 38.8% (n = 19) of the participants were nurses whilst over 24.5% of the participants were medical officers and pharmacists. The mean years of practice was 7.7 (± 5.6) with almost half (44.9%, n = 22) of the participants having practiced for between 1 and 5 years. Majority (59.2%, n = 29) of the participants were involved in the management of patients with Alzheimer's disease (Table 1).

Relationship between demographic characteristics and participants' knowledge on Alzheimer's disease at pre-test and post-test
At pre-test and post-test, factors associated with participants' knowledge were their profession (p = 0.007; p < 0.001), professional rank (p = 0.008; p < 0.001) and the highest level of education attained (p = 0.007; p = 0.008) ( Table 3).

Predictors of participants' knowledge on Alzheimer's disease at both pre-test and post-test
The results of the multiple linear regression after adjusting for age and sex showed that participant's rank was an independent predictor of knowledge on Alzheimer's disease using ADKS at pre-test.

Participants' resolutions and recommendations
From the five groups with interprofessional representation, some resolutions and recommendations made included the need for greater multidisciplinary and multisectorial collaboration, increased public education on ADRD, provision of financial and social support and expansion of geriatric services to cater for people living with ADRD and their families (Table 6).

Discussion
By 2050, the number of people living with ADRD is projected to hit 106.8 million 10 and this calls for increased awareness, identification of knowledge gaps and institution of appropriate educational interventions for relevant stakeholders. Comparable with our findings, an earlier study found the ADKS questionnaire to be a useful tool in identifying education needs of health workers and assessing effectiveness of education efforts. 12 In this study, in which 59.2% of the participants indicated some involvement in managing patients with Alzheimer's disease, their mean ADKS at pre-test was 19.8 (± 4.28) and this significantly increased to 23.2 (± 4.01). These mean scores amongst HCWs were higher than 11.7 ± 3.02 obtained amongst elderly Egyptians 14 but lower than 20.15 to 27.40 reported by Carpenter et al in the United States. 13 Our participants' knowledge scores increased in all seven ADKS domains. In a previous study, domains with significant ADKS scores were assessment, treatment and management and the participants recorded the least scores in the risk factors and prevention domains. 13 The ADKS is predicted to produce different scores for various categories of health workers, based on their experience and theoretical knowledge. 12 In our study, type of profession and years of practice did not impact the ADKS scores. However, a participant's rank was an independent predictor of pre-and post-test scores. Those with post-graduate medical qualification, considered specialists and comprised 18.4% of the participants, recorded the highest overall scores. These were specialists in family medicine, internal medicine and psychiatry who practice at primary, secondary and tertiary level facilities. This implies that in our setting, specialists can lead capacity-building efforts across various levels of care. It also suggests the need to intensify education interventions for the 81.6% HCWs below the specialist rank. The bulk of these HCWs work in primary care settings. Perhaps, the 4-h duration of the workshop was inadequate and this category of HCWs may benefit from a more prolonged training engagement.
The baseline (pre-test) scores and the improvement in scores in both content areas and in specific questions point towards areas that might need extra attention in future efforts to build knowledge on ADRD in the HCW in Ghana and other similar countries.
Resolutions shared by the participants are quite insightful and critical to addressing ADRD challenges, which may be provider-related, patient-related or health system-related. Participants recommended inclusion of medications for managing ADRD in the National Health Insurance Scheme (NHIS) and provision of financial support for families living with the disease. With an estimated $156 billion worldwide direct cost of dementia and a projection of higher costs in developing countries, 8 there is the need for system-based financial cushioning. In spite of its challenges, Ghana's NHIS and health insurance schemes in other parts of the world have been a source of financial reprieve for the poor and vulnerable. 15,16 Another recommendation by participants is the provision of geriatric services at various health institutions in Ghana and creation of an aged-friendly and supportive environment. This calls for intense education. An interprofessional, team-based approach in which various categories of health workers are trained and their expertise harnessed was an important recommendation by our participants and this has been touted as an innovative strategy. 17,18 Our workshop, which assembled a wide spectrum of health workers, has therefore provided a foundation for future collaborations in ADRD-related activities in Ghana.

Strengths and limitations
The findings of this study are very relevant, as to our knowledge, this is the first to be carried out in sub-Saharan Africa using ADKS among HCWs whose role in addressing the looming ADRD epidemic cannot be overemphasised. The sociodemographic and professional characteristics of the participants were varied and quite representative of HCWs in Ghana. Previous studies have been undertaken in Egypt and the United States amongst different populations. Unlike these earlier studies, ours goes beyond highlighting domains with knowledge gaps to analysing pre-and posttest scores after a training session. Our study is limited by the relatively small sample size and the 4-h engagement with participants. In addition, being a cross-sectional study, we are limited in our ability to generalise our findings. Future studies should target a larger population of participants.

No. Resolutions and recommendations
1 There is the need to take detailed and accurate patient history.

2
There is the need for collaboration between general practitioners, the mental health units and community health nurses.

3
Patients should be involved in their diet planning.

4
There should be increased public education on the condition.

5
Social workers should be involved in the care of patients.

6
Stigmatisation and profiling of patients should be discouraged.

7
Toxicity and efficacy of medications should be monitored. 8 Counselling and emotional support should be provided for caregivers of people with dementia.

9
Clinical trials on Alzheimer's disease should be explored.

10
Encourage physical activities in management of Alzheimer's disease.

11
Include Alzheimer's disease medications on National Health Insurance Scheme (NHIS).

12
Adopt multidisciplinary and holistic approach in the management of Alzheimer's disease. 13 Geriatric, family medicine and other related specialist clinics should be established at every hospital.
14 Hospital environment should be friendly to welcome patients with ADRD.

15
There should be a national policy for financial support for patients and families with persons suffering from Alzheimer's disease. 16 Review patient's drugs in order to stop non-essential medications.

17
Avoid unnecessary physical restraints on patients and protecting patients from potential physical harm.

18
Form dementia support group for patients with ADRD and their caregivers.

19
Provision of a toll-free hotline for caregivers of ADRD patients.

20
More training for health workers and caregivers on Alzheimer's disease.

Conclusion
Knowledge gaps on ADRD exist amongst Ghanaian HCWs and educational intervention where local expertise help train a sample of HCWs improved scores on ADRD by four units. Amongst others, we have recommended NHIS funding of ADRD management, intensification of education at the primary care level, expansion of geriatric services and interprofessional collaboration. Increased awareness amongst the general population and training of a critical mass of health professionals are needed to care for sufferers and support families grappling with the debilitating effects of ADRD.